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11 <br />Designated Underground Storage Tank (UST) Operator <br />Monthly Visual Inspection Checklist <br />Facility Name: <br />Date: <br />Facili Address: <br />Cit <br />Zip Code- <br />Designated UST Operator Conducting the Inspection: <br />Monitorinst system is not current!y showing any alarms or warnings. <br />International Code Council Certification #: <br />Si ature: <br />Expiration Date: ! J <br />Phone: <br />Y = Yes. N m No. NA - Not APPUcable <br />Item <br />MONITORING PANEL / ALARM HISTORY Y N NA <br />1 <br />Monitoring s stem is powered on and inro er oErating mode. <br />2 <br />Monitorinst system is not current!y showing any alarms or warnings. <br />3 <br />Alarm history report/log for the previous month is available, and has been reviewed by the <br />Designated UST Operator. Attach a copy of the alarm history Mor!/lo to thist available. <br />4 <br />,form <br />Each alarm for the previous month has been respondedwappropriately. <br />5 <br />Sensors located in tank-to2 containment sumps have not alarmed in the past month. <br />Sa <br />List all tank -top sumps where alarms occurred in the past month: <br />Note: Siartps where an alarm has occurred it: the past month naat be hspected tmiess a qualified service technician responded to. and <br />property addressed. the cause g0be alatrn. Attach documentation rerffying appropriate service to this report. <br />Ifstimp inspection is required. record resuhs tat trent 6. below. <br />UST SYSTEM INSPECTION <br />F6Tank-top <br />containment sumps are free of water, debris, and hazardous substance. Sensors are located properly. <br />ote: Yistrat in cdott of'srum s is only re mired in stem s where an alamu has occurred in the st mouth or which there is no service record. <br />YN <br />t Location: <br />Y N <br />Sum Location: <br />Location: <br />Sunt Location: <br />Location: <br />Sump Location: <br />7 <br />S ill containment structures are free of water, debris, and hazardous substance. <br />Y N I NA Y N NA <br />Tank 1 - Contents: Tank 3 - Contents: <br />Tank 2 - Contents: Tank 4 - Contents: <br />8 <br />Under -di eraser containment areas are free of water, debris, and hazardous substance. Sensors are located ro erl . <br />Y N NA Y N NA <br />Dispenser 1 / 2 Dispenser 9110 <br />Dispenser 3 / 4 Dispenser 11 / 12 <br />Dispenser 5 / 6 Dispenser 13 114 <br />Dis enser 7 / 8 Dis nser 15 / 16 <br />PAPERWORK INSPECTION Y N NA DATE DONE <br />9 <br />Monitorin s stem certification has been completed within past 12 months. <br />10 <br />Seconds containment tests have been completed within the r wired timeframe. <br />11 <br />Spill containment structure bucket testing was com leted within the East year. <br />12 <br />Tank ti tress testing was completed within required timeframe. <br />13 <br />Line tightness testing was completed within required timeframe. <br />14 <br />Other required testin maintenance was completed within r uired timeframe. List test/maintenance items below. <br />Test/Maintenance: <br />Test/Maintenance: <br />Test/Maitrtenance: <br />FACILITY EMPLOYEE TRAINING Y N NA <br />15 <br />All facili employees have received the required on-the-'ob training within the ear. <br />16 <br />All facility em Io ees hired within the past 30 days have received the Leguired on-the-job training. —f7H <br />Note: Any answer of `°N" should be explained in the comment section on the following page, and will require <br />follow-up action. <br />Page I of 2 November 2004 <br />